Mood disorders Flashcards
(115 cards)
1
Q
Define mood disorder
A
Mood altered from normal - elevated or lowered
2
Q
What % of global population is affected by MDD at any given time
A
2-7%
3
Q
Another name for mood disorders
A
Affective disorders
4
Q
Is MDD more common in men or women and by how much
A
Women
2x (diagnosed)
5
Q
MDD age of onset trend
A
Decreasing
6
Q
Does MDD affect an age group most
A
PH Scotland GP visits - peak in 30s/40s but affect all ages
US data - peak in 18-25
7
Q
Factors to consider in world wide epidemiology of depression
A
Differences in culture, healthcare systems and diagnostic criteria
8
Q
Economic burden of depression in USA (amount)
A
$210 billion - now probably $300+
9
Q
Describe the contributions to economic burden other than actually caring fro those with depression
A
Caring for those with depression - less than half
Suicide costs - a v small proportion
Loss of productivity (workplace costs) - majority
10
Q
Describe what people are actually treated for as a consequence of depression (and proportions)
A
Depression (MDD and other) - 50%
Comorbidities - the rest - people with depression have a much higher rate of illness
11
Q
Name 2 physical co-morbidies of depression
A
CVD
Diabetes
12
Q
What % of global population has BPD
A
1%
13
Q
Onset of BPD
A
Often early (15-19)
Rarely after 40
14
Q
Are there any gender differences in the epidemiology of DBP
A
No
15
Q
Name the 2 diagnostic manuals used for mood disorders and who they are published by
A
DSM-5 (APA)
IDC-11 (WHO)
16
Q
Areas where there are differences between DSM and ICD
A
Classification of disorders
Diagnostic criteria
17
Q
What is MDD
A
Monopolar/unipolar depression
18
Q
What is dysthymia
A
Low level depression for a long period of time (years)
Common
Many people with it don’t realise they have it
19
Q
Another name for BPD
A
Manic depression
20
Q
What is BPD
A
A period of depression followed by a period of mania
21
Q
DSM-5 conditions for MDD diagnosis
A
Experience 5 criteria in a 2 week period (must include one of depressed mood diminished interest/anhedonia)
Must cause distress or impairment
No other cause
22
Q
What is anhedonia
A
Loss of pleasure/joy in almost all actitivites
23
Q
Name 5 diagnostic criteria for MDD in DSM-5
A
Depressed mood (can be irritable mood for children)
Anhedonia
Sleep disturbance (in or hypersomnia)
Fatigue/loss of energy
Feeling of worthlessness
24
Q
How reproducible is DSM-5 MDD
A
Low reproducibility - long list of criteria - need 5 for diagnosis so 2 patients could have a completley different set of symptoms
Means MDD is more umbrella for a group of disorders
25
What is included in DSM-5 to address the low reproducibility in diagnosis
Specifiers
26
What are diagnostic specifiers
Added onto diagnoses to describe extra/specific features
27
Name 5 common specifiers for MDD
With anxious distress
With atypical features
With melancholic features
With post partum onset
With seasonal pattern
28
What do the following MDD specifiers describe :
mild, moderate, severe, with psychosis, in partial or full remission, single/recurrent
Severity and course
29
For which MDD specifier is lack of joy the main symptoms
With melancholic features
30
Name 5 symptoms of with melancholic features specifier
Lack of joy
Insomnia
feelings of guilt
Psychomotor retardation
Anorexia
Dinural mood variations - worse in mornings
31
For which MDD specifier is the ability to feel joy the main specifier
With atypical features
32
Name 5 symptoms of MDD with atypical features
Ability to feel joy
Weight gain
Worse in evening
Increased sleep
Sensitive to rejection
Anxiety
33
Which diagnostic manual does NICE use for depression
DSM-IV
34
Differences between DSM-5 and NICE diagnosis of depression
NICE use a severity level based on number of symptoms
35
NICE conditions for MDD diagnosis
At least one of persistent sadness/low mood or marked loss of interest or pleasure
Most days for at least 2 weeks
If so are there are other associated symptoms
36
Associated symptoms in NICE MDD diagnosis
disturbed sleep
disturbed appetite
Fatigue/loss of energy
Feelings of worthlessness
37
What is the number of symptoms for each NICE severity level
Sub-threshold = less than 5 (DSM-5 requires 5 for diagnosis)
Mild = 5 or a few more than 5
Minor functional impairment
Moderate = functional impairment between mild and severe
Severe = most symptoms present - marked interference with functioning
Can occur with or with our psychosis
38
Which differences between ethnic groups are shown in US MDD data
Increased rates in white Americans and mixed race compared to other ethnicities
May reflect differences in access to healthcare
39
Describe BPD
Depressive episodes and major manic episodes
40
Diagnostic criteria for depressive episodes
Same as for MDD
41
Suicide rate in BPD
Very high - 35% attempt
42
DSM-5 conditions for BPD diagnosis
Key criteria present most of the time for at least a week + 3 others (4 other if irritable mood)
Must cause marked impairment
43
What are the 3 criteria of manic episode in DSM-5
Abnormally elevated
Expansive or irritable mood
Persistent increase in activity/energy
44
What are the other DSM-5 criteria in BPD
Inflated-self esteem/grandiosity
Decreased need for sleep
More talkative
Flights of ideas/racing thoughts
Distractability
Increase in goal directed activity
45
What is a consequence of many of the manic symptoms of BPD
Involvement in damaging activities - hyerpsexuality, gambling, spending
46
Can a manic episode have psychotic features (delusions/hallucinations)
Yes
47
Name 2 subtypes of mania
Hypomania
Mixed episode
48
What is hypomania
Less impairment
Mildly elevated mood/energy level
Change in functioning but can still be highly functioning
Often seen as a personality trait
49
What is a mixed episode
Simultaneously depressed during manic episode
Even high risk of suicide as have energy to carry out ideation
50
What are the 3 BPD subtypes
BP1
BP2
Cyclothymia
51
What is BP1
Classic manic depression
Full blown mania and periods of MDD
52
What is BP2
Hypomania and periods of MDD
53
What is cyclothymia
Hypomania and mild depression for more than 2 years
(think similar to dysthymia for MDD)
54
What is rapid cycling BPD
An add on to diagnosed of BP1 or BP2
More than 4 episodes in 1 year
55
What are 4 brain regions that undergo atrophy during MDD
Prefrontal cortex
Anterior cingulate cortex
Amygdala
Hippocampus
56
Evidence for hippocampal atrophy during depression
Sheline et al (2003) found negative correlation between hippocampus size and time with untreated depression
57
What do PET scans show
Glucose metabolism or blood flow in brain areas
58
Drevets et al (2008) findings
PET scans - reduced activity in prefrontal cortex
But reduced volume suggests this is a result of reduced cell numbers rather than reduced activity in each individual cell
59
What is the role of prefrontal cortex in emotional regulation and how is reduced activity implicated in MDD
Inhibits the hypothalamus
Hypothalamus regulates cortisol levels
So reduced PFC activity means increased hypothalamus and cortisol activity
60
Meta analysis findings on amygdala in MDD
Reduced volume
Hyperactivity in response to negative/sad stimuli
Underactivity in response to positive stimuli
61
3 roles of amygdala in emotional regulation and how is it implicated in MDD
1. Evaluation of emotional stimuli - threat, social significance, reward value etc
overactive for sad stimuli, underachieve for positive stimuli
2. Helps organise emotional experience and expression
3. Involved in all types of reaction to stress/threat situation (endocrine, autonomic and behavioural reaction) - excess amygdala activity reflected in abnormalities in all of these seen in depression
62
What is a brain area with aberrant activity in BPD
Prefrontal cortex
63
Describe prefrontal cortex activity in BPD
based on glucose metabolism/PET
Decreased activity during depressive episode
Increased activity during many episode
64
Further evidence for importance of prefrontal cortex in emotional regulation
Suicide attempt that damaged prefrontal cortex:
One ameliorated depression
One caused personality change from aggressive to docile and inappropriately happy
65
Name 2 theories of depression
Monoamine hypothesis
HPA axis
66
What is the monoamine hypothesis of depression
Caused by defects in MA transmission
5HT and NA
67
Evidence for monoamine hypothesis - explain
Iproniazid
Reserpine
Serotonin levels
Tryptophan depletion
Current treatment
68
Criticism fo MA hypothesis
Current treatment acts at MA transmission in mns/hours but there is a 2-4 week delay before AD effects are produced
69
What does HPA axis stand for
Hypothalamic pituitary adrenal axis
70
What does the HPA axis theory of depression propose
Chronic stress leads to dysfunction of the HPA axis, prefrontal cortex and hippocampus
71
What is CRF/H
Corticotrophin releasing factor/hormone
72
Where is CRF released from
Hypothalamus
73
Where does CRF act on and what does it promote
Pituitary gland
ACTH secretion
74
What is ACTH
adrenocorticotrophic hormone
75
Where is ACTH released from
Pituitary gland
76
Where does ACTH act and what does it promote
Adrenal cortex
Cortisol secretion
77
Physiological function of cortisol
Increases glucose availability
78
How are cortisol levels regulated in healthy people
Negative feedback - cortisol acts on glucocorticoid receptors in pituitary gland and hypothalamus to inhibit secretion of CRF and ACTH so decreases cortisol production
79
What % of depressed patients have a hyperactive HPA axis
50%
80
What % of severely depressed patients have hyperactive HPA axis
80%
81
What is the dexamethasone depression test used for
To test whether HPA axis feedback is working
82
What is dexamethasone
A potent synthetic glucocorticoid - acts on anterior pituitary gland and hypothalamus reducing CRF and ACTH and thus cortisol
83
By how much does dexamethasone reduce plasma cortisol in healthy and in depressed patients
What does this suggest
85% in healthy
45% in depressed
Loss of regulatory feedback
84
What is thought to cause loss of regulatory feedback of HPA axis in depression
Chronic stress
85
Describe features of chronic stress in depression
Elevated cortisol levels (over prolonged period)
But reduced action of negative feedback loop
Increased CRF levels
So further increase in cortisol levels
86
Name 3 non-HPA brain areas that cortisol and CRF act on
Hippocampus
Amygdala
Prefrontal cortex
87
What is the effect of cortisol and CRF in hippocampus, amygdala and prefrontal cortex
Increased apoptosis
Decreased neurogenesis
So atrophy --> seen in these areas in depression
88
What do the hippocampus, amygdala and prefrontal cortex regulate in the HPA axis
Hypothalamus
89
What is another level of regulation of HPA axis lost in depression
Dysfunction/atrophy in amygdala, hippocampus and PFC in depression - lose proper regulation by them of hypothalamus in addition to loss of cortisol negative feedback loop
90
Criticism of the HPA axis hypothesis
Some people undergo sustained stress and don't become depressed
IT is probably a combination of genetic (polymorphism) and epigenetic factors
91
Relationship between epigenetics and HPA axis
Those who suffered early childhood trauma or deprivation have HPA hyperactivity which persists through adulthood even if they are not currently depressed
92
Environmental factor that increases risk of depression as an adult
Childhood trauma
Deprivation
93
Overlap between MA and HPA hypotheses - explanation of delayed AD effects
ADs (target MA transmission) may increase neurogenesis and decrease apoptosis in brain regions which show atrophy in depression (inc amygdala, hippocampus and PFC)
So function restored in these brain regions (may take time - delayed AD effects)
In turn these restore regulation of HPA axis
This reduces cortisol and CRF levels - so also lose their negative effects at atrophy brain regions
94
Possible advantage of identifying genetic factors for mood disorders
Mood disorders are heterogenous so identifying genetic factors may allow tailored treatment
95
Define concordance
% change that one win will develop a disorder if the other twi already has it
96
What does 100% concordance suggest
Good evidence for genetic factor
97
What does concordance between 100% and the prevalence of the disease int he general population suggest
There may be a genetic factor
98
Confounding factors in twin studies
Twins share similar environments (esp in early life) - nature vs nurture
Likely to share experience of early childhood trauma
99
What % of the MMD risk is genetic according to GWAS
40%
100
Name 5 genes in which polymorphisms are associated with MDD
SERT gene - increase risk by 20%
DAT gene - strong association (more than SERT)
Dopamine D4 receptor gene - strong association (more than SERT)
G protein subunit beta 3
Methylenetetrahydrofolate reductase
101
Describe dopamine implication/research/drugs in MDD
polymorphisms in DAT and D4-R have strong association with MDD
Little research done into DA and MDD
Suggested that sertraline may inhibit DA at high doses
Other DA active drugs development as ADs have been withdrawn due to side effects
102
Name 2 genes in which epigenetic changes are associated with MDD
Mineratlocorticoid receptor - receptor for CRF
FKBP5 - a protein which modulates sensitivity of the glucocorticoid receptors
Other HPA axis genes
103
Evidence that BPD is heritable
Up to 80% twin concordance found
104
Role of genes in mood disorders
No single gene
contributions from a number of risk factors (genes and environment) produce a small increase in likelihood
105
Name 3 genes that increase risk of BPD according to GWAS
ANK3
CACNA1C
TRANK1
106
What does ANK3 encode
ankyrin B - involved in myelination
107
What does CACNA1C encode
Voltage gated Ca channel in brain - may be involved in development and signalling
108
Effect of mood stabilisers on TRANK1 gene
Mood stabiliser increase the expression of its product (not understood)
Also associated with Schiz
109
Name 4 explanations of why depression is still present despite evolution
Behavioural shutdown
Acceptance of subservient position
Psychic pain
Rumination
110
What is behavioural shutdown
Learned helplessness - conserve energy when impossible to overcome a stressor
Can be applied to withdrawing from everyday activities furlong food shortages - aligns with the sickness behaviours seen in people with depression
Illness in the past - best chance would have been to stay put to avoid predators - hypervigilanece may have been an advantage in this position - aligns with high levels of anxiety in depression
111
What is acceptable of subservient position
To survive with a dominant animal best bet is to be subservient
112
What is psychic pain
Physical pain tells us to withdraw from damaging stimuli - psychic pain in depression may do the same e.g. withdraw from stressful activities
113
What is rumination
depressed people better at solving some kind of problems
Shut down of some behaviours may allows us to focus on certain types of problems and find a solution - may be important in solving social e.g. whether to stay in relationship
114
What does PHQ-9 stand for
patient health questionnaire 9
115
What is the PHQ-9 and what is it used for in the UK
A version of DSM-5 depression symptoms broken down into frequency of symptom
Allows you to self-assess
